Curbing Opioid Abuse Doable, Report Suggests

by David Pittman David Pittman Washington Correspondent, MedPage Today
December 05, 2012

Tactics designed to limit potential abuse of opioid painkillers while maintaining pain control, as outlined by the Alliance of Community Health Plans, can be easily replicated elsewhere, advocates believe.

The methods -- already in use by many health plans -- encourage providers to adopt evidence-based prescribing guidelines, work with pain specialists to transition off highly addictive opioids, and store care plans in patients' electronic medical records.

"I think that what we've done can be absolutely replicated in other settings," Joel Hyatt, MD, assistant medical director at Southern California Permanente Medical Group, told MedPage Today. "But it does take physician leadership. I don't think this is the kind of thing that can be either legislated or mandated by a health plan."

Opioid abuse and overdose has received increasing attention, and at least part of the healthcare community has tried to mobilize to reduce it. Four times more Americans died from prescription opioid abuse in 2009 than in the decade prior.

The alliance's report gives examples of how various health plans are combating the problem. For example, at the Kaiser Permanente group, only oncology, pain management, and hospice physicians can prescribe oxycodone (OxyContin) and oxymorphone (Opana).

"We've embedded decision support or alerts that pop up whenever I want to prescribe an opioid medication," Hyatt said, referring to Kaiser's vast electronic medical record system.

The system will suggest alternatives to medication for pain management such as physical therapy, acupuncture, and nonsteroidal anti-inflammatory drugs.

"It doesn't prohibit any of our providers from prescribing this medication." It does inform, educate, and provide links to clinical practice guidelines and suggest pain management consultation, Hyatt said.

Also, Kaiser's pharmacies don't fill prescriptions when there are questions about possible misuse and abuse.

In the last 2 years, Kaiser has reduced the prescribing on OxyContin by 70% while offering what plan officials believe is good pain management. In that time, they've also reduced the prescribing of brand-name opioids such as Vicodin, Norco, and Lortab -- drugs with a high street value for diversion -- by 80%.

Those are just some of the many examples of steps being taken to prevent opioid abuse.

"I really haven't heard of any idea I think is a bad idea," Andrew Kolodny, MD, chair of psychiatry at Maimonides Medical Center in New York, told MedPage Today.

Even if practices don't have a vast electronic medical record, there are simple steps physicians can take to reduce opioid abuse, such as educating patients about the risks of the opioids, cross-checking names against a controlled substance prescribing database to see how often patients have received such drugs, and even testing blood for traces of the drug before writing a prescription.

The real answer to the drug abuse is to start fewer people on this treatment in the first place, physicians said. And there is no evidence that higher-dose regimens are more effective.

"Long-term use of opioids is not an evidence-based practice," Michael Von Korff, ScD, senior investigator at Group Health in Seattle, told MedPage Today. "It's not going to be a simple solution to chronic pain."

There are big individual differences in how patients respond. Some do well and others end up addicted. "It's a treatment that should be undertaken very, very cautiously," Von Korff said.

At Group Health Cooperative, all patients on chronic opioid therapy must develop a care plan with their physician, discuss the risks and benefits of treatment, and obtain instructions for follow-up. Doctors refer patients on high doses to pain specialists if their underlying condition isn't improving. That guideline became state law this year.

Between 2007 and 2011, Group Health cut in half the percentage of noncancer patients on high-dose opioids and reduced the average daily dose of painkillers by a third.

Pharmacies, pharmacy benefit managers, and physician groups also need to join the game, advocates said. The American Medical Association and state medical societies have largely been silent on the issue but could play a huge role in doctor habits.

"It's not just the individual physician acting alone," Hyatt said. "I think there are physician groups that could take on this opportunity and challenge ... and make it part of their agenda."

The AMA took strong exception to Hyatt’s claim that it hasn’t done enough to promote safe prescribing habits.

"The AMA has devoted significant resources on several fronts to combat prescription drug diversion and abuse while preserving access to medically necessary treatment for pain," AMA President Jeremy Lazarus, MD, told MedPage Today in a statement.

"We support rapid implementation of medically appropriate policies at the federal and state levels to address both the supply and demand side of this epidemic," he continued. “Equally important, the AMA and its partners in the medical community have committed resources to promote physician education and awareness, as well as strategies to treat addiction and reduce the incidence of overdose and death.“

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